Basic Information
| Provider Information | |||||||||
| NPI: | 1861454704 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAULK | ||||||||
| FirstName: | WILFORD | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25317 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336225317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132860033 | ||||||||
| FaxNumber: | 8132821806 | ||||||||
| Practice Location | |||||||||
| Address1: | 14546 OLD SAINT AUGUSTINE RD STE 311 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322585472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042602255 | ||||||||
| FaxNumber: | 9042602251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 02/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | ME 48260 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207V00000X | ME48260 | FL | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 064742000 | 05 | FL | MEDICAID |